Medical malpractice lawsuits stemming from lost airways are among the most devastating — and the most avoidable. Consider these 3 malpractice suits and the potentially grave consequences of difficult airways, and examine how the right preparation and techniques can help you steer clear of similar outcomes.

Case 1 Should This Patient Have Been Intubated?
What happened: A patient suffered a stroke after undergoing endoscopic cholangiography for a retained bile stone. She filed a lawsuit claiming the anesthesia team administered excessive sedation without an adequate airway, resulting in hypoxic injury. The patient also alleged the anesthesiologist and the facility failed to adequately train and supervise the nurse anesthetist to recognize and treat the compromised airway. A jury found the anesthesiologist breached the standard of care, but ruled his actions weren't the cause of the patient's injury. The court also ruled that the nurse anesthetist didn't breach the standard of care.

Why it happened: The patient claims that she was given a large dose of a sedative without being intubated. It's likely, however, that the complication resulted from premature extubation while still in the excitement phase of anesthesia. Patients are predisposed to laryngospasm during this time, which causes loss of airway, or an inability to secure the airway.

How it could've been avoided: Planning and preparation. Laryngospasms can be life-threatening. If laryngospasm occurs, it can be broken by applying continuous positive pressure ventilation, or by administering a low-dose muscle relaxant and securing the airway. Better yet, don't place your patient or yourself in this position. Test the airway before intubation. Make sure you can ventilate the patient and ensure your patient meets extubation criteria at the end of the procedure. Always have a high suspicion index, and be familiar with the American Society of Anesthesiologists' (ASA) difficult airway operation guidelines (tinyurl.com/7twa3md).

Case 2 Why Not Local Anesthesia for Minor Case?
What happened: A patient went for minor surgery to have a small cyst removed from his left forearm. An anesthesiologist induced general anesthesia with a laryngeal mask airway (LMA). Airway difficulty ensued. The first LMA was removed, and a second LMA was inserted in an effort to correct the difficulty. That also failed. The anesthesiologist induced a paralyzed state to intubate the patient, but was unable to do so. The patient suffered a cardiopulmonary arrest and didn't respond to resuscitation attempts. The patient has since passed away. An appeals court ruled that the hospital, anesthesia team and nurses named in the suit must stand trial for failed intubation.

Why it happened: Theoretically, inserting the first LMA in this case wasn't a bad call. But initial airway difficulty is an ominous sign. The anesthesia team should have called for help after the second failed airway attempt, or abandoned the procedure and awakened the patient. Instead, persistence prevailed, and the patient was intubated, which resulted in failure to secure the airway and subsequent hypoxia.

How it could've been avoided: This patient entered the facility for the removal of a "small" cyst, and the outcome was fatal. Why wasn't local anesthesia considered? Why subject any patient to a general anesthetic when another, less invasive technique can accomplish the required surgical aim? Failure to offer the technique, surgeon refusal, poor local infiltration technique, anesthesiologist disinterest and production pressures could've all played a part. Pressure to go faster and do more generally leads to shortcuts in patient safety. But regional anesthesia was another viable option to consider in this case.

Targeting the administrative team for inadequate training is a relatively novel approach for a malpractice claim, and signals that the plaintiff is going for the deeper pockets of the facility itself. It's noteworthy that the anesthesiologist is no longer part of the suit, likely settling out of court.

Case 3 Did Failed LMA Insertion Cause Patient's Death?
What happened: An anesthesiologist's continued use of an LMA to intubate a patient scheduled for a biopsy allegedly caused the patient's airway to swell and close. The patient, who had previously undergone radiation therapy for neck cancer, became cyanotic and required an emergency tracheotomy. She sustained injuries to her lungs, surgical emphysema of the upper chest, neck, face, orbits and head, and bleeding and incision of the thyroid gland. The patient died a year later from ongoing complications secondary to the tracheotomy. A lawsuit filed by the patient's husband alleged the doctor should have used a different anesthesia method to secure the airway, and failed to discuss with his wife the options of intubation by LMA or fiber-optic intubation. A jury found the anesthesiologist wasn't liable for the complications that arose due to failed LMA insertion. An interesting finding, in my view.

Why it happened: This patient's history should have been a major red flag. Radiation of the neck can affect the airway by distorting and structurally damaging anatomy to the point that standard intubation is literally impossible. On its face, the decision to insert an LMA may have been adequate, given the surgical site and the fact that a muscle relaxant didn't have to be used. This approach is less invasive in terms of manipulating and securing the airway. But the problem with using an LMA for a patient who has undergone radiation in the past is the lack of a plan B — tracheal intubation — should the LMA fail.

How it could've been avoided: Depending on the size and location of the tumor, the anesthesiologist should have instead considered local anesthetic, especially when airway compromise is known or at least suspected. The team could've also considered other techniques such as video laryngoscopy or elective tracheotomy. An in-depth anesthesia work-up — history and physical exam, body habitus, specific airway testing like Mallampati and Cormack/Lehane — can be predictive of airway challenges. This patient's airway history dictates that the procedure should have been done in a hospital, where more educated hands and equipment are available to help in a crisis.

Expect the unexpected
There's a common thread running through these 3 cases: The failure to appreciate patient presentation and consider alternative methods led to catastrophic outcomes. Potential problems weren't addressed before the event. These outcomes could be attributed to the pressures that outpatient centers are under to increase patient volume. These pressures can lead to shortcuts that compromise patient safety.

Pressures and other excuses aside, these healthcare professionals aren't without blame. These patients and their families looked to the anesthesia provider to be their advocate and protect them during their procedures, and these cases show questionable decisions and varying degrees of fault. Proper planning would've gone a long way toward preventing these difficulties and subsequent litigation.

We talk about the "unexpected difficult airway," but there really shouldn't be such a thing. Don't be surprised by a difficult airway. Rather, the difficulty should trigger a well-thought-out plan for rescue. Take time to properly evaluate the airway, and expect the unexpected. Outward appearance of normal anatomy does not guarantee a positive outcome, and you must maintain a healthy respect for anesthesia. If you become too complacent in your approach to anesthesia delivery, it's time for a career change or retirement, before you injure a patient. We refer to some procedures as "minor surgery," but there's never a "minor anesthetic." Failure to heed the warning could very well harm a patient, and land you in a courtroom.